Arterial spin-labeled (ASL) perfusion in children with Sturge-Weber syndrome: a retrospective cross-sectional study

PURPOSE

Sturge-Weber syndrome (SWS) is a developmental disorder with venous hypertension and associated tissue responses including pial angiomatosis, cortical calcifications, and cerebral atrophy. Arterial spin-labeled (ASL) perfusion is an advanced MR sequence which can assess perfusion, without the need for contrast. We systematically evaluated the potential benefits of using ASL in Sturge-Weber syndrome, to determine the extent of intracranial perfusion abnormality and stage of disease, relevant for prognostication and surgical planning.

METHODS

Two pediatric neuroradiologists retrospectively evaluated ASL perfusion imaging of 31 children with confirmed SWS and recorded the presence of hyper-perfusion, hypo-perfusion, or normal perfusion. The presence and distribution of ASL abnormality were compared against the presence and side of atrophy/calcification and pial angiomatosis on standard MR sequences.

RESULTS

Thirty-one children (52% female, median age 16.7 months) with SWS had ASL imaging. Seven (23%) had hyper-perfusion, 15 (48%) had hypo-perfusion, and 9 (29%) had no perfusion abnormalities. ASL perfusion abnormality matched the location of SWS findings on conventional imaging in 86% (19/22). ASL demonstrated statistically significant increased perfusion in the early stage of the disease and decreased perfusion when there was atrophy. The parietal lobe was involved in 86% of cases.

CONCLUSION

ASL perfusion imaging is an advanced technique which may contribute to earlier diagnosis and more accurate prognostication of Sturge-Weber syndrome, helping guide management and potential surgical planning.

Pseudoangiomatous stromal hyperplasia: A clinical perspective and a brief review

ABSTRACT

Pseudoangiomatous stromal hyperplasia (PASH) is a benign entity of the breast and typically found incidentally or as a palpable mass. It usually affects women in the reproductive age group. In men, it is associated with gynecomastia. While the exact etiology is unknown, PASH is considered hormonally responsive. The mammography and ultrasonography findings are nonspecific. Grossly, PASH is a well-circumscribed, firm, rubbery mass with solid, homogenous, gray-white cut surface. On histologic examination, it is characterized by the presence of open slit-like spaces in dense collagenous stroma. The spindle cells express progesterone receptors and are positive for vimentin, actin, and CD34. PASH lesions should be surgically excised if increasing in size or associated with symptoms, also in cases of suspicious imaging findings or other lesions are synchronously diagnosed that require excision. In other small incidentally detected asymptomatic cases observation with clinicoradiological follow-up can be considered. It is associated with a good prognosis with no increased risk to develop breast cancer. Hence, the operating surgeon and pathologist should be aware of this not so uncommon entity so that patients are not subjected to unnecessary excision and subsequent physical and mental morbidity associated with it. In this article, we present a case report and also provide a brief review of the sparse literature on PASH, discussing clinical presentation, etiology and pathogenesis, radiopathological features, differential diagnosis, and the implications for further patient management and prognosis.

Revision of the cystic angiomatosis of the bone]

INTRODUCTION

Bone cystic angiomatosis is a disease with only 200 cases described, based on angiomatous nonmalignant proliferation, in bone tissue and viscera. It focuses on pelvis, long bones and scapular waist. Clinical evolution ranges from self-limiting forms to massive aggressive osteolysis (Gorham-Stout).Its diagnosis is of exclusion, with nonspecific clinical, radiological (lytic images) and histopathological findings.

CLINICAL CASE

Our study is based on the clinical case of a 14-year-old man diagnosed with bone cystic angiomatosis, with disseminated bone involvement, who came to our center for pain and functional impotence in the right hip, diagnosing a pertrochanteric fracture. It was operated by open reduction and osteosynthesis with four-hole VERSA sliding plate screw. An allogeneic graft of cancellous bone was used from femoral head. The evolution was satisfactory, with ambulation at full load per month without requiring analgesic medication and control X-ray at eight months that showed signs of complete integration of the graft. The analgesic pain scale (visual analogue scale) showed a score of 2/10 per month.

DISCUSSION

There is controversy regarding the treatment of these fractures by osteosynthesis with bone graft. We are facing a case without serious clinical criteria, but with multiple foci of osteolysis. It was decided not to intervene prophylactically the contraleteral hip, since it is asymptomatic and there are different patterns of evolution described in the literature and risks in surgery.

Structural analysis of human NHLRC2, mutations of which are associated with FINCA disease

NHLRC2 (NHL repeat-containing protein 2) is an essential protein. Mutations of NHLRC2, including Asp148Tyr, have been recently associated with a novel FINCA disease (fibrosis, neurodegeneration, cerebral angiomatosis), which is fatal in early childhood. To gain insight into the mechanisms of action of this essential protein, we determined the crystal structure of the Trx-like and NHL repeat β-propeller domains of human NHLRC2 to a resolution of 2.7 Å. The structure reveals two domains adjacent to each other that form a cleft containing a conserved CCINC motif. A SAXS structure of full-length NHLRC2 reveals that the non-conserved C-terminal domain does not pack against the N-terminal domains. Analysis of the surface properties of the protein identifies an extended negative electrostatic potential in the surface of the cleft formed by the two domains, which likely forms a binding site for a ligand or interaction partner(s). Bioinformatics analysis discovers homologs across a range of eukaryotic and prokaryotic species and conserved residues map mostly to the adjacent surfaces of the Trx-like and β-propeller domains that form the cleft, suggesting both that this forms the potential functional site of NHLRC2 and that the function is conserved across species. Asp148 is located in the Trx-like domain and is not conserved across species. The Asp148Tyr mutation destabilizes the structure of the protein by 2°C. The NHLRC2 structure, the first of any of its homologs, provides an important step towards more focused structure-function studies of this essential protein.

Angiomatoid fibrous histiocytoma: a case report and review of the literature

Angiomatoid fibrous histiocytoma (AFH) is a rare soft tissue tumor most commonly occurring in children, adolescents, and young adults. Clinically and radiographically the lesion is easily confused with a hematoma, soft tissue hemangioma, or malignant fibrous histiocytoma. While the lesion is rare, due to the potential for local recurrence and metastasis, it is imperative to consider this lesion in the differential diagnosis of a soft tissue mass in a child or adolescent. Here, we present the clinical, radiologic, and pathologic findings of a case of AFH.

Pregnancy in a patient with the Klippel-Trenaunay-Weber syndrome: a case report

A rare case of pregnancy in a patient with the syndrome of Klippel-Trenaunay-Weber is described. The arterio-venous anomalies in this patient originally occurred in her right leg, but in the course of her first pregnancy she also developed circumscript angiomatosis at the left and right side of the uterus. Her pregnancy was uneventful. However, because of prominent vascular changes in the cervix and lower uterine segment, there appeared to be a cephalo-pelvic discongruency. For this reason a Cesarean section was performed at term. Postoperatively, during heparinization, she had signs of abdominal bleeding, which could be controlled conservatively. There were no signs of intravascular coagulation or cardiac decompensation. A review of the scarce literature on diffuse uterine angiomatosis and angiomatosis occurring as a result of the syndrome of Klippel-Trenaunay-Weber is given. The clinical course and the risks of a pregnancy with this condition are discussed. It is concluded that the angiomatosis based on the syndrome of Klippel-Trenaunay-Weber is less hazardous than a diffuse angiomatosis of the uterus without this disease, the main risk being diffuse intravascular coagulation at or after delivery.

Sturge-Weber disease without facial nevus

A rare case of Sturge-Weber syndrome without facial nevus and epileptic seizures is reported. The other cases of incomplete form of the disease reported in the literature showed occipital calcification and epileptic seizures without facial nevus, while in the present case also the convulsions were absent. The possible pathogenic mechanism is discussed. The CT findings of these incomplete forms include unilateral or often bilateral occipital calcifications with no evidence of contrast enhancement. The Authors conclude that the radiologic finding of bilateral gyriform calcifications in the occipital region must suggest the diagnosis of Sturge-Weber disease even in the absence of facial nevus and epileptic seizures.

Klippel-Trenaunay-Weber syndrome with spinal arteriovenous malformation--case report

A 28-year-old female with Klippel-Trenaunay-Weber syndrome associated with an arteriovenous malformation (AVM) of the spinal cord is reported. She was admitted to our hospital with a 4-month history of steadily progressive weakness and dysesthesia of the legs. A nevus flammeus, varices, hypertrophy and elongation of the left leg had been present since her infancy. These symptoms progressed and she became unable to walk and pass water by herself. Myelography disclosed a spinal AVM extending from Th11 to L2. Angiography confirmed the presence of stretched and tortuous vessels as well as an arteriovenous shunt in the left leg. Magnetic resonance imaging showed a high-intensity area extending from Th10 to L2. Following laminectomy from Th10 to L2 and resection of the AVM, her motor and bladder functions worsened. However, 6 months later, her motor function improved to the preoperative state and the bladder dysfunction disappeared. The coexistence of Klippel-Trenaunay-Weber syndrome with spinal AVM, considered to be rare, is discussed, and the pertinent literature is reviewed. The case presented here is the first to have been surgically treated in Japan.

[Klippel-Trenaunay syndrome with complications during pregnancy]

In Klippel-Trenaunay syndrome there are congenital vascular malformations, usually involving the limbs. It is characterized by extreme varicose veins, bone and soft tissue hypertrophy and pigmentary skin changes in the affected limbs. We report a 29-year-old pregnant woman with this syndrome. The combination of the physiologic changes which occur in the vascular system and in blood coagulation during pregnancy, and the malformations of this syndrome is very unusual. During the patient's pregnancy there was significant worsening of the typical complications. There was extreme dilatation of varicose veins in the left leg, from the ankle up to the posterior aspect of the buttock. The involved area was swollen and edematous, and there were signs of superficial thrombophlebitis. Because we were unable to rule out deep vein thrombosis in the affected limb, prophylactic anticoagulant treatment was given during the 3rd trimester and into the early puerperium. Only then did the complications begin to resolve, but return to the prepregnant state was incomplete.

Klippel-Trenaunay-Weber syndrome (angio-osteohypertrophy syndrome)

Images

[Maffucci's syndrome (dyschondroplasia combined with hemangioma)]

Dyschondroplasia as congenital, non inherited mesodermal dysplasia is known as most seldom disease in the classical sense with hemangioma as Maffuccis Syndrome in literature. Two cases not previously described are presented and discussed with reference to world literature. In the foreground we see distortion of the chondroma deformity, less often is the development of malignity as a result of the hemangioma.

Trabeculectomy for adolescent onset glaucoma in the Sturge-Weber syndrome

Two patients with adolescent onset glaucoma associated with Sturge-Weber Syndrome have been presented. Both patients were successfully treated with ab externo trabeculectomy. This procedure is suggested as an additional means for controlling the late onset glaucoma associated with the syndrome without provoking additional complications or deterioration. Early treatment is emphasized before the irreversible changes of chronic glaucoma become manifest.

Sturge-Weber syndrome

Encephalotrigeminal angiomatosis (Sturge-Weber syndrome) is described with a typical case history.

[Klippel-Trenaunay-Parkes-Weber syndrome with spinal cord angioma]

É relatado um caso de síndrome de Klippel-Trénaunay-Parkes-Weber associada a angiomatose medular. O autor salienta ter encontrado na literatura somente uma referência com tal associação.

[2 new cases of Klippel-Trenaunay syndrome]

After a brief account of the history and pathogeny, two cases are described of sub-angiomal bone hypo and hypertrophy. Other cases in the literature are recalled. Finally, a differential diagnosis is given.

Klippel-Trenaunay syndrome. A case report and review of the literature

Clinical and radiological assessment of a female patient suffering from varicose veins revealed many of the features first described by Klippel and Trenaunay. The findings are presented in detail and the lymphographic features are illustrated. The previous literature is briefly reviewed.